Lung Cancer Screenings
Vascular Healthcare Screenings
Clinical Decision Support Program
Mammography Patient Screening
Have you had a prior mammogram?
Are you having any breast problems?
Please specify which breast(s) and explain:
Is your appointment today the result of these problems?
Have you had breast cancer?
Has any blood relative had breast cancer BEFORE age 50?
List age of relative at diagnosis:
Have you had breast surgery?
Please give the dates for the following:
Lumpectomy (for cancer)
Are you presently taking hormone replacement?
Are you pregnant?
Are you breastfeeding?
Please check all of the following that are true for you:
I do not know my personal breast cancer history
I have had endometrial cancer
I have had ovarian cancer
I have the BRCA 1 gene mutation
I have the BRCA 2 gene mutation
A family member has had ovarian cancer
I have been through menopause
I have never had children
I had my first child after age 30
I have had previous chest radiation therapy
I have had a previous breast biopsy that showed a high risk lesion